Nokea
The nurse would classify a newborn delivered at 39 weeks' gestation, weighing 2400 g ( 5.0 lbs) as being:
- A. Preterm and immature
- B. Small-for-gestational age
- C. Average-for-gestational age
- D. Average-for-gestational age but pre-term
Correct Answer: B
Rationale: The correct answer is B: Small-for-gestational age. A newborn delivered at 39 weeks' gestation and weighing 2400g is considered small-for-gestational age because the weight is below the 10th percentile for the gestational age. This indicates intrauterine growth restriction. Preterm and immature (choice A) would not apply as the baby was delivered at term. Average-for-gestational age (choice C) would not be accurate as the baby's weight is below the normal range for that gestational age. Choice D is also incorrect as the baby is not within the average weight range for the gestational age.
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A patient 11 weeks' gestation comes to the emergency room department with c/o dizziness, abdominal pain, and shoulder pain. Lab tests reveal a beta-hcg lower than expected level for gestational age
- A. Ultrasound confirms no intrauterine
- B. The nurse knows the most likely diagnostic is an ectopic pregnancy. What statement should the nurse use to explain to the patient?
- C. The baby is in the fallopian tube, the tube has ruptured and is causing bleeding
Correct Answer: B
Rationale: Step 1: Recognize Symptoms - Dizziness, abdominal pain, shoulder pain, low beta-hcg.
Step 2: Consider Ectopic Pregnancy - Symptoms align with ectopic pregnancy.
Step 3: Rule Out Miscarriage - Low beta-hcg indicates not viable intrauterine pregnancy (Choice A).
Step 4: Understand Ectopic Pregnancy - Explaining ectopic pregnancy (Choice C) and rupture to patient may cause distress.
Step 5: Communicate - Nurse should use simple, empathetic statement (Choice B) to explain the likely diagnosis.
Summary: Choice B is correct as it addresses the likely diagnosis without causing undue distress to the patient, unlike Choices A and C which may lead to confusion and anxiety.
What do you give for magnesium sulfate toxicity?
- A. Calcium gluconate
- B. Sodium bicarbonate
- C. Furosemide (Lasix)
- D. Vitamin K
Correct Answer: A
Rationale: The correct answer is A: Calcium gluconate. In magnesium sulfate toxicity, high levels of magnesium can lead to muscle weakness, respiratory depression, and cardiac arrest. Calcium gluconate is given because it antagonizes the effects of magnesium on the neuromuscular system and helps prevent further complications. Sodium bicarbonate (B) is not the correct choice as it is used to treat acidosis, not magnesium toxicity. Furosemide (C) is a diuretic and would not address magnesium toxicity. Vitamin K (D) is used for blood clotting disorders, not for magnesium toxicity.
A client at 37 weeks' gestation reports sudden gush of clear fluid. What is the nurse's priority action?
- A. Assess for fetal heart rate changes.
- B. Check maternal vital signs.
- C. Perform a sterile vaginal examination.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: The correct answer is A: Assess for fetal heart rate changes. This is the priority action because the sudden gush of clear fluid may indicate rupture of membranes, potentially leading to fetal distress. Assessing fetal heart rate changes helps determine the urgency of the situation and guides further interventions. Checking maternal vital signs (B) is important but not the priority in this scenario. Performing a sterile vaginal examination (C) should only be done after confirming rupture of membranes to prevent infection. Notifying the healthcare provider (D) can be done after assessing fetal well-being.
Which is a priority nursing intervention for a post-operative patient who has had an incomplete abortion?
- A. Insertion of IV line and fluid replacement
- B. Methergine IM (Clerie said this one to diminish bleeding, but Quizlet said bolded answer)
- C. Positioning client on left side
- D. Preop teaching for surgery
Correct Answer: A
Rationale: The correct answer is A: Insertion of IV line and fluid replacement. This is the priority nursing intervention for a post-operative patient with an incomplete abortion because fluid replacement is essential to address potential hypovolemia from bleeding. Ensuring adequate IV access allows for prompt administration of fluids and medications to stabilize the patient's condition. Choice B, Methergine IM, may help reduce bleeding but is not the immediate priority. Choice C, positioning the client on the left side, is not as urgent as fluid replacement. Choice D, preop teaching for surgery, is not relevant in this post-operative scenario.
What does intimate partner violence refer to?
- A. violence that occurs in public spaces, such as streets or parks, between acquaintances or strangers
- B. violence or abuse that occurs within a relationship, involving physical assault, sexual violence, emotional or psychologic abuse, controlling behaviors, and economic abuse
- C. violence primarily directed toward children by their parents or guardians
- D. violence that is limited to verbal arguments and does not involve physical harm
Correct Answer: B
Rationale: The correct answer is B because intimate partner violence refers to violence or abuse that occurs within a relationship, involving various forms of abuse like physical assault, sexual violence, emotional or psychological abuse, controlling behaviors, and economic abuse. This definition specifically highlights the nature of violence within the context of intimate relationships, distinguishing it from violence that occurs in public spaces (choice A), violence directed toward children (choice C), or limited to verbal arguments without physical harm (choice D). Choice A is incorrect as it focuses on violence between acquaintances or strangers in public spaces. Choice C is incorrect as it refers to violence toward children. Choice D is incorrect as it excludes physical harm, which is often a significant aspect of intimate partner violence.